Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Monday, May 23, 2016

A few weeks back I mentioned nurse practitioners. These are nurses who have gone on to get a Master's Degree so they can work alongside or independently of physicians as higher-level providers of medical care. Nothing wrong with nurses wanting to get more education and advance their career, of course, and more power to them for doing so. What I didn't realize, however, is that much of the class time in spent in nursing research. This strikes me as kind of a fluffy topic (no traditional nursing-based pillow tasks pun intended), because I can't figure out what nursing research is. If we're trying to figure out what clinically works for patients in the real world, we're dealing with the same issues, and the same set of facts, whether the research is done by doctors or nurses. That’s why it’s called clinical research. It’s not doctor research. So I don't quite get what nursing research is if it's not research into clinical care. And if it's not, then that means it's not fact-based, and risks getting lost in rubrics of good feeling and a cornucopia of psychobabble. This is not really a criticism; it's the nature of the beast when you try to quantify that which is inherently subjective. It's a problem when subjectivity becomes confused with fact, and extrapolations are made on unfounded assumptions. You know, like pain scales and patient satisfaction measures.

(For the record, research that is fact-based does not mean that it's useful or even worthwhile finding out. It's like those studies that appear from time to time as a Waste of Government Dollars, like the one in England a few years back that showed that the girls really do get prettier at closing time. Mickey Gilley knew that years ago, as did his cousins Jerry Lee Lewis and Jimmy Swaggert. As well as anyone who went home at two with a ten and woke up at ten with a two. Not sexist; it works both ways.)

I was talking the other night with one of my nursing friends who's just finishing up her nurse practitioner degree, and she was telling me about their class research project. (This particular nurse is also savvy about why nursing research is so prominent in her curriculum. "The professors have us do a project, write it up, stick their names on it, and submit it to see if they can get published." Yet another way nursing academics are exactly like their physician peers.) She and her classmates have spent the better part of a year trying to figure out why patients with emphysema (more specifically known as Chronic Obstructive Pulmonary Disease, or COPD) don't get the care they need. They've come up with the usual suspects: lack of access to health care, lack of financial resources, lack of health education, and the like. In the end, it seems like in health care, like everything else, it always seems to come down to money...money that drives access to care, to medications, to resources, to education, and even to time to devote to health care and maintenance. But as we discussed her project, we realized that in our rush to blame the system and absolve individuals from accountability...not a specifically medical issue, but a systemic one...we simply ignore all those factors that result from individual free will. There are those who quite actively choose to continue to smoke, to not take advantage of free health care resources, to not use their prescribed medicine as directed, to refuse home oxygen when suggested by the physician. In the shorthand of the ER, we term these behaviors as idiocy.

It seemed to me as we talked that we could make this problem a lot easier if we focused on money and idiocy as driving forces for healthy behaviors. And we could do so in a diagram:

IDIOT?

YesNo

YesBadHooray!

MONEY?

NoBadBad

In brief, if you're an idiot, bad things happen. If you're not an idiot, but don;t have money, bad things happen. If you're not an idiot and you have a few bucks, you'll be fine. That's all of health care behavior in a nutshell. And depending on how high up the food chain we consider the idiot, probably explains a lot about the healthcare are system as well.

See how easy this can be?

(In reflecting upon this solution, I recognize that I have now personally put any number of nursing, social science, and economics journals out of business, have destroyed tenure for countless academics, and have simplified doctoral theses for any number of graduate students. The only thing left now is to define the extent and the operational mechanisms of idiocy, which in itself remains an expansive topic of study, one that women have been trying to figure out in men since the first Australopithicus said, "Hey, I can walk upright! Guess that lion can't eat me now!" And I have distilled the collected works of Will and Ariel Durant, Jared Diamond, and Yael Noel Harris, all excellent scholars of civilization, into a Cliff Notes version. You're welcome.)

Tuesday, May 17, 2016

Have you
ever had a chance to fulfill a childhood dream? Has there been something you've
longed for all your life, and now with hard work, effort, and a little bit of
scratch you can finally live out your fantasy?

Meet Bob.
Bob grew up in the Midwest and now lives in sunny California, so when he comes
to Kansas City in April and feels the hint of chill in the early morning air,
he harkens back to the halcyon days of childhood. He thinks about laying in the
grass under a cloudless summer sky, snowball fights on Christmas Day, and
romping through untamed woods and gullies where endless gated communities now
hold court. The only black mark in this nostalgic idyll is knowing that he
never had the pet he always wanted. Sure there were animals in the house, but Nip
the Dog was really his brother's boon companion, and Tab the Cat...well,
belonged to herself, as cats will do. No, he never had a pet that was just his,
something that he could hug and pet and squeeze and pat and rub and caress just
like Hugo the Abominable Snowman and his Pink Bunny.

Fast forward
thirty years. Bob's a success. In demand, well respected, flying all over the
country to add to his riches. He's got a wonderful wife, two great kids, two
cars, and a few pets that, just Iike before, seem to love someone else in the
household more than him.

So he
wakes up one morning in the Midlands, having finished his work a day early and
with a full twenty-four hours to himself. He gazes around his hotel suite, the
expensive one with the the soaking tub and the mini-bar that doesn't charge you
every time you jostle a Pepsi, and he thinks, "Today. Now."

He goes
to the specialty pet store. There's something specific he wants, and he's spent
the morning researching where to find it. He buys an airplane carrier for it,
too, because he's going to take it back to California to show his wife and
kids, hear their squeals of delight and their sighs of admiration, and hug it
and pet it and squeeze it and pat it and rub it and caress it.Buying this pet is Bob’s ultimate act of
self-actualization.

He buys
it and names it Bosco. He keeps it in the box from the pet store nail the next
morning, when it's time to enter the pet carrier and get on the plane. But
Bosco likes the box, and is young, and afraid, and so Bosco bites. And chews,
and won't let go.

Did I
mention chews? Oh, right. I forgot to tell you. Bosco is a Gila Monster.

Here's
the scoop on the Gila Monster. It's one of the two poisonous lizards native to
the United States , the other being the Mexican Beaded Lizard. They are found
wild throughout the American Southwest. For the record, that's not Kansas. Our
native lizards could be fine domestic companions, which can be surmised by the
fact that nowhere does the word "monster" appear in their names.

Gila Monsters normally live
underground, are generally shy and retiring, and it seems to take a special
effort to get bit by one.This says
something about Bob.But you don’t have
to take my word for it:

“I have never been called to attend a case of
Gila Monster bite, and I don’t want to be.I think a man who is fool enough to get bitten by a Gila Monster ought
to die.The creature is so sluggish and
slow of movement that the victim of it’s bite is compelled to help largely in
order to get bitten.”-Dr. Ward, Arizona Graphic, September 23, 1899

(While we're speaking of Hispanic
lizards, and especially in this Trumpian moment, I'm reminded of a display at
the Oceanographic Museum of Monaco. There's a tank of small amphibians from
Mexico, really cute little fellows that run about and jump on sticks and eat
bugs and look out at the tourists. The adjoining wall is adorned by a cartoon
version of one member of the company, dressed in a sombrero and holding a pair
of maracas, greeting visitors with a warm, “Hasta la vista, muchachos!”It's so cute that not only do you not want to
build a wall to keep them out of the country, but you'll even gladly consider
setting up terrariums along the Rio Grande and provide them with free sticks,
bugs, health care, and college tuition for those eggs that hatch. Of course, it
would never fly in America, but I suppose when your version of undocumented
aliens from south of the border are Syrians you can get away with that.)

Bosco is
chewing. He likes this. He has yet to bond emotionally with Bob, and for the
moment thinks of Bob not as his pal for life, but as a probable threat that
just happens to be soft, fleshy, and possibly quite tasty. Bob is macaroni and
cheese, meat loaf, cream gravy; Bob is comfort food. So Bosco keeps chewing,
and won't let go until Bob grabs the carrier with one hand, sticks his other
arm, (Bosco attached) into the box, and whacks his newfound friend against the
rigid plastic walls of the enclosure to make him break his group. Bob thinks
things are going well as he quickly clips the door shut.

Did I
mention that the Gila Monster is poisonous? And that the reason he chews is
because, unlike rattlesnakes who inject their poison through their fangs in
less than an instant, the venom of the Gila Monster slowly flows into the bite
along grooves in the lizard's teeth. So the only way it has to kill it's
struggling prey (or his new best friend) is to chew like there's no tomorrow.
Which, with the life span of a Gila Monster being about a quarter that of a
human being, there may not be.

The swift
blows having done their job, Bosco is back in the carrier and it's time to head
to the airport. Except that as Bob drives, he notices his hand swelling. A lot.
And it's turning colors, reds and blues and purples that he's only seen in
formal photos of the British Royal Family. So Bob does what any normal person
would do in our technological age. He asks Siri to find him the nearest ER.

The
clinical care here is really an afterthought. There are local effects such as
pain and swelling, and more general effects that include weakness and drops in
blood pressure.The physician evaluates
the extent of the swelling to determine if there's vascular compromise that
will require emergent surgery (fasciotomy, a particularly nasty procedure) to
release pressure on the blood vessels of the hand. You get some basic lab tests,
start some fluids and give pain medication, and wait. If things seem to be
getting worse, with more swelling, increasing pain, or unstable vital signs,
it's time to find out where the nearest anti venom is. If not, you are often
able to discharge the patient home. Above all, you get everyone you know
(perhaps even flagging down a couple of truckers at a nearby rest stop) to come
see the patient because...let's be honest...Gila Monster bites are cool, and
patients need to be gawked at to be fully engaged in the Teaching Moment of
Animal Safety. As paperwork is always important, it's my understanding that in
cases like this the American Medical Association has concluded it is not a
breach of medical ethics to use the terms "stupid" or
"idiot" in clinical documentation.

What's
more fun is imagining the next day. His right hand freshly bandaged and
splinted, narcotics on board, Bob gets on the flight home. It's an airline
where you can bring a pet onboard as long as it fits in a carrier beneath the
seat. So someone...it could be me...is sitting next to Bob. There's an angry
Gila Monster near my feet, longing to chew through the walls of the carrier and
quite possibly my shoe, sock, and second metatarsal. For me and my fellow
passengers, it's the most nerve-racking three hours in the air since Samuel L.
Jackson had to cope with airborne serpents.

Meanwhile,
Bob is trying to figure out how to explain to his wife that not only did he
purchase a Gila Monster, got bit by a Gila Monster, and almost lost his hand to
that very same Gila Monster, but he is also bringing home that very same Gila
Monster to hug it and pet it and squeeze it and pat it and rub it and caress it
and watch it bite Nip the Dog and Tab the Cat and Delores the wife and Anna the
Daughter and Bob Junior the Son, because there's nothing that brings a family
together like poison-produced pulpy purple puffy painful wounds, even without
the added fun of possible necrosis. And Bob's also reviewing his grade school
knowledge of fractions, so he can figure out exactly how much he's going to
have left in his bank account when Bosco crawls in and Delores walks out.

And as
for me, sitting alongside Bob, my eyes in constant vigil as an evil hiss works
it's way towards my ears from under the seat in front of me?

Monday, May 9, 2016

The Dental Empress and I recently made our second trip to an IKEA store. For those of you who are not familiar with IKEA, it's a Swedish company that...well, I'll let them tell you from their website."The IKEA Concept starts with the idea of providing a range of home furnishing products that are affordable to the many people, not just the few. It is achieved by combining function, quality, design and value - always with sustainability in mind. The IKEA Concept exists in every part of our company, from design, sourcing, packing and distributing through to our business model. Our aim is to help more people live a better life at home."Kitty litter also accomplishes the same goals, but that's not what IKEA does. What they really do is design and sell ingenious thematic, space-saving, low cost, build it yourself furniture and related home accessories for urban living. My understanding of urban living might be tempered somewhat by the fact that I've never been a resident of a core urban area, but I think it means residing in extremely tiny and outrageously expensive cubicles in neighborhoods alive at night with the noise of millennial lamenting the capitalism of their parents that got them their college degrees and the lack of safe spaces to whine about it, or in places you probably shouldn't hang out after dark.

IKEA is very a cool place. The showroom...and it's huge, not just like a really big Wal-Mart Superstore but Donald Trump HUGE..is laid out in a way that you have to see everything is order to get anything. (This promotes impulse buying of things you never knew you needed, which is why I now have an eight-pack of wooden hangers new kitchen tongs, a battery-powered alarm clock, and two stuffed animals. A fluffy puppy and a Daddy fox with a kit, if you must know.) The products themselves are often quite clever. Designed to maximize function in minimal space, they open, close, expand, contract, twist, and turn, and are able to be mounted on walls, floors, and ceilings in ways you'll never expect short of a zero-G space station. My favorite part of the store is where they've constructed a model apartment with a full kitchen, bathroom, bedroom, living/dining room, and a spare alcove bedroom in less than 600 square feet. It's brilliant stuff.

(Just so you know, I didn't buy everything. For example, I put down the fire-engine red heart-shaped pillow with arms that I think are supposed to enfold your child to give them a big hug. Instead, I picked up the pillow and made the arms flail me about the head and face, telling the Empress it was a heart attack. That didn't go over well.)

It's also important to note that everything belongs to some sort of complimentary set, and that each set has a Swedish name. None of these are Swedish words you may have heard of. There is no ABBA four-piece place setting, no Garbo entertainment center, no Vasa sink, no Stockholm Syndrome. Instead, the collections have names like. Oppland, Liatorp, and Stocksund, which according to the Google Translator seem to be made-up words to describe the style, kind of like I'm pretty sure the made-up word "Frito" is a descriptor for the real-life noun "Bandito."

So as I was idly looking about while the Dental Empress was taking careful notes to make sure we got the Malm dresser rather than the Hemnes one, I noticed that all the books on the shelves used to fill out the displays are the same. It seems there are about ten individual titles in the entire store, but each one has been used hundreds of times on the shelves. And these are not hollow plastic imitations of scholarship; they complete hardcover books fully printed on each page, umlauts and all. You almost get the sense that IKEA is single-handedly supporting the entire Swedish publishing industry, making works such as "Smultron och Svek" a perennial best-seller. It reminds you of one of those late-night 1980's commercials for Slim Whitman, who reportedly outsold the Beatles in Bulgaria. In a similar vein, you could also say that Annica Wennstrom has sold more than one million books worldwide, without mentioning that 987,000 of them serve as unread fodder in IKEA stores.

(Interestingly, where CD's are supposed to be represented, there are only empty jewel boxes. Which means that I have more Swedish music in my home than does IKEA, because I not only have ABBA Gold but also a 1990's CD by Tomas Ledin featuring the song "Du Kan Lita Pa Mej," which I think means "You Can Lita on My Mej." I know this because I also used to watch late-night 1980's commercials for the children's game Husker Du.)

The way IKEA works is that as you work your way through the store you pick out what you like, and if there are things that don't fit into your basket you go to the attached warehouse to load up the big items so you can build them yourself at home. And so few hours later, a bit of Sweden has been dragged into the house. ("Look! It's like they're pooping!" exclaimed The Empress as we opened just the end of an eight-foot box, tipped the unopened side skyward, and watched the pieces cascade, one by one, out onto the floor.) Buried within each carton was a set on instructions. The thing the remember is that as an international brand, IKEA has to be able to communicate with anyone regardless of language. So the instructions use pictures only, and the first page begins with a few introductory cartoons. The cartoons show the wrong way to do things on the left, and the correct way to do them on the right. It's kind of like Goofus and Gallant in the old Highlights for Children. ("Goofus leaves as quickly as he can while you're asleep and doesn't leave a phone number. Gallant makes coffee in the morning and says he had a wonderful time.") So one of the cartoons shows a person sobbing because there's a crack in his project from building it on the hard floor; the corresponding picture shows him smiling with the project safely cushioned by a carpet. Another one shows a puzzled man looking at the instruction book; the adjacent drawing shows him calling IKEA for advice. And them there's the picture of one unhappy person looking at a stack of prefab pieces and parts next to two happy ones gazing at the same pile. The message is clear. It takes two.First project is the dresser. The Empress has a tool kit in her house. It contains one ladylike lavender hammer, eight flat head screwdrivers (all the same size) and one narrow Phillips head item, a pair of pliers, a packet of Allen wrenches, and forty plastic cable ties in a rainbow of colors and hues. She also has one cordless drill for which there are no drill bits, but she uses as a power screwdriver. Because I try to obey the admonitions on the right side of the Highlights page (Gallant says "Please use the cordless drill and save your delicate hands;" Goofus says "Go screw yourself"), every minute or so I hear a chirpy, "I'm done! It's because I have a power tool!" Meanwhile, I'm still working on upgrading from moderate to severe carpal tunnel syndrome ratcheting in the second of eight screws, Part #10863. Because I am a supportive boyfriend, I look up and smile at her every time she does this, fighting every urge I have to make some sort of remark about her and power tool (and you can guess where this might have gone, especially in a commuter relationship).

We made it past the drawers in good order, carried the dresser into the closet where it will reside, and put together the storage unit with a minimum of fanfare. The entertainment center, however, was another matter entirely. Multiple boxes, misplaced rods and ratchets, and difficulties fitting pieces together made it a less than joyous coulee experience. The pot came to a boil after I asked her to tip the piece as a whole up so I could attach the top, and as it did I heard the sickening crack of particle board, splitting the wood over both of the bolts that would secure the bottom of a piece backing up the TV to the rest of the structure.

"F--k a duck with a f-----g duck f---k.!" I exclaimed. (Even when I curse, I like alliteration)

She peered at my with Marlin Perkins interest. "You're mad."

"No, I'm not. I'm frustrated. That's different," I lied.

"Well, it's not my fault. I helped just like you told me to."

I can see where this is going. I'm going to try to bail out the sinking ship, but still make my point. Bad move.

"You're right. I should have told you to keep a hand on that piece while it was moving so it wouldn't fall backwards. I thought you would do that and I didn't specifically tell you to. It's my fault."

"Yes. Well, it's fine." (Fine is never a good word in a relationship.) "It's on the back and nobody will see it."

"No, it's not okay. It's not fully structurally intact. I don't think it's a major problem but it's not okay."

I'm not the most self-aware person, but one thing I do know is that after the initial explosion, my voice drops a few scales and I start talking in a slow, measured fashion. I'm now in full James Earl Jones, deep Mississippi mode. She knows this. She thinks it's hysterical that this is the only thing that can shut up my otherwise constant chatter.

It's now the sound of triumph tinged with just enough righteousness. "No, it's not."

It's at this point that I'm looking around the room for some kind of distraction, and my eye falls upon the last page of the instruction book. And it's at that moment that I realized why there was no cartoon of happy people rejoicing over the finished product after the final step. The Swedes may be many things, but they are not liars. For not only have they lured you into buying their products, they are now going to play the ultimate Nordic prank on you, the one that makes up for them all having Seasonal Affective Disorder and being unable to uproot Julian Assange from the Bolivian Embassy. They knew that the after picture should show only the finished project, and not the carnage in blood and relationships that follow.

Despite the temporary setback, the Empress and I set things right. We managed to back the entertainment center into a corner so the broken piece is leaning against a wall. And then we went to a local bistro and had two bottles of wine and smoked a hookah flavor called 50 Shades. Afterwards it was 1 AM Steak N Shake for Takhomsak Chili Mac with extra cheese. Gallant says, "May I pour you a nightcap?" And The Empress says, in her best Eva Gabor voice, "Of course, dahling." It's all good.

(PS: For more information about Sweden, I would refer you to The Suite Life on Deck, "The Swede Life." In a related note, The Teen tells me that the question of London or Bailey is this generation's version of the "who do you choose" quandry. And just so you know, the correct answers to the classic questions are Mary Anne, Julie Newmar, Veronica Lodge, Jennifer Marlowe, and the Green Orion Slave Girl.)

Monday, May 2, 2016

Death is final. The end. El fin. It's the existential dread of Homo sapiens, the only species we know of that contemplates it's own mortality. So it's surprising to me how many people come to the ER and say they want to die. Their numbers keep rising, and it's a fair argument to try to figure out why and to assign the requisite blame. (I've even heard the suicide rates of middle-class white men being tied to the rise of Donald Trump.). But while there are truly desperate people out there who need genuine help, it may be surprising to learn that they're usually not the ones who I see in Sinatra's wee small hours.

That is not to diminish the very real pain of those who are truly hopeless. The ones we're talking about those for whom an attempt at suicide is just an event. People who actually want to commit suicide see it as a resolution. They are they ones who often present in advance, recognizing their suicidal thoughts but not wanting to surrender to them. These are the true "cries for help," and with a bit of experience you can identify them almost immediately. Their despair is palpable, the air between you thick with emptiness, and as you talk you begin to feel that suicidal thoughts are probably not a sign of illness, and that suicide is a conscious, rationale, and even reasonable option. And there are truly suicidal patients who are found by friends or family unconscious and unresponsive, keeping everyone in the dark about their plans, and who are genuinely disappointed that it didn't work and often puzzled by their failure because they've done their research in advance. These are the people in true crisis for whom we should bend every rule and twist every arm to get them the help they need.

Ah, but then there's the rest, the ones who make up bulk of our "suicidal" clientele. These are the folks who respond to life's stressors by chasing down some vodka and few Tylenol, perhaps guzzling down a handful of their psych medications for good measure, and then call everyone they know (and especially the ex) to let them know they're killing themselves. There is wailing, thrashing, and tears. There is also a lot of texting and cellular calls. This is not a cry for help. This is attention-seeking behavior, or (to use a technical term) a "dramarama." It's the ER equivalent to the Security Theater performance of the Transportation Security Administration.

While experience gives you a gut feeling abut who's really suicidal and who's not, there are some objective clues to guide the neophyte. First, there's no lethal mechanism involved. This might not have been a clue in the pre-Internet era, but today anyone with a cellphone can figure out how much of what medicine to take to kill themselves. Similarly, if you want to kill yourself by jumping, or with a gun, you don't sit on the railing of a bridge and think about it until someone pays attention, or wave your gun around to make sure it gets noticed. And speaking of cellphones, if you've texted and called people (especially the ex...that wasn't a joke) to let them know what you're doing, you're not in it for real. And they don't put it on a "to do" list, as did one patient whose list, on a thin notepad festooned with flowers and tiny kittens, included things like "buy groceries" and "kill myself." (I'm not making this up.) People who truly want to commit suicide just get on with it.

A second clue is that the patient, when confronted with the fact that their "attempt" is going to result in consequences, is suddenly no longer suicidal. Patients with psychiatric disorders can certainly have labile moods, but you can't turn depression on and off like a light switch ("It's a clever little Mormon trick."). You don't go from wanting to quit life to laughing and smiling when friends and family (and especially the ex) arrive, ideally to fawn over your poor lost soul. One of the questions I always ask patients is, "If I gave you a clean and painless way to kill yourself right now, would you do it?" It's the ones who immediately answer "yes" in a firm voice, no tears, looking me straight in the eye that I worry about. If you're investing your energy in weeping and wailing and calling and texting (there's that cellphone again) and wondering where your beloveds (mother, father, boyfriend, girlfriend, or ex) is, you've got no intestinal fortitude for what you claim to have done.

A corollary to this is that patients who are not truly suicidal refuse to cooperate with care when informed that labs may need to be drawn and they may be held in the ER for psychiatric screening, claiming they have "rights' and we can't "make them do anything." We do inform them early n that since they made a suicidal gesture, the law obliges us to hold them for their own safety until they are cleared; and that we hope that they'll cooperate with us in what we need to do. The truly suicidal accept this with resignation. They're beyond caring what happens to them or why. The dramatists rebel, and sometimes it gets ugly. They're also the ones who specify what hospital admissions and discharge plans are acceptable to them, and threaten to call their lawyer. (Standard response: "Go ahead.") But no matter what they ask for a meal tray and a Sprite within 45 minutes of arrival. You can time it.

It also shouldn't be forgotten that there are other kinds of secondary gain from claiming suicidal thoughts or tossing down a few pills. There are a number of "regulars" who are quite skilled at playing the "suicide card." If you have no place to stay, you now get food and lodging for at least a night at a local psychiatric clearinghouse. If you were going to jail, perhaps now you don't. If you're lucky, maybe you even get admitted to the hospital and Case Management invests time in finding you a place to live or getting you signed up for benefits and services. And if nothing else, at least you have time to sober up in a warm, clean place. The psychiatric clearance process often takes time, and at night that usually means you're with us 'til sunup.

So for many patients who come is with a suicide attempt, especially involving an overdose, they know it's all about attention just as we do. But our medicolegal system, as well as our cultural belief that no one is responsible for their own actions, means that we have to maintain some kind of fiction that something needs to be done rather than just simply calling someone out on their script. That fiction is called the psychiatric screen, and the resultant "Contract for Safety," where the patient agrees in writing to call for help as needed and to follow-up with counseling., because every truly suicidal person is going to be help up by a signature on copy paper.

But here's the paradox of clinical practice. I really don't mind taking care of these folks. It's fun to watch the show. It's admittedly kind of a power trip to tell people what they can and can't do know that they're on your turf, and watch their faces as they realize they've set events in motion far beyond their control. They're easy patients as well; with very few exceptions, modern overdose management is simply watchful waiting. And from a workload standpoint, it's great. They often need several hours of observation based on the peak blood levels of the drug they took, and then several hours after that to arrange a psychiatric disposition. Which means they clog your rooms up for quite some time, decreasing your patient turnover and ultimately your overall workload. The bean-counters who have never touched a patient but still grade you on throughput time as a measure of "quality" hate it, but from the standpoint of the working doc they prolonged ER stay in entirely justifiable and quite welcome, thank you very much.

(This is where I take moment to lament the loss of a what we might call "educational" therapy. It is often true in medicine there are both easy and hard ways to achieve the same result. For instance, I can resolve a case of gonnorhea with with a shot in the butt of an antibiotic called Rocephin or with a large oral dose of a different antibiotic. Which one you get depends on how you've treated the ER staff, and if I think you're the victim or the perpetrator. If I think you need a strong disincentive to your continued risky behaviors, or you've been a jerk yo the nurses or to me, you get the shot. It's educational, in that you learn the difference between acceptable and unacceptable behaviors. Twenty years ago, we had a lot of "educational therapy" in overdose management. We'd take these huge half-inch plastic tubes called Ewalds and shove them down the patient's throat into their stomach, under the premise that we were going to wash out their stomach with a tube big enough to get out all the pill fragments. Or maybe we'd just give them a nice big slug of ipecac so they could vomit and puke and upchuck for hours on end. These actions would not only be therapeutic, but serve as disincentives to engage n the same behavior in the future. Alas,science has deprived us of some of it's fun, as it turns out that with rare exception there really re no pill fragments to go after, and by the time the patient gets to the ER there's really nothing left in the stomach to barf up. About all we get to do is make you drink some grainy powdered charcoal...just like in your grill but without the impregnated lighter fluid...if you show up within an hour of your overdose. Maybe if you refuse the urine test we restrain you and pass a catheter into your bladder, but that's about it anymore. Sigh.)

Most of the one-act plays we see are attempts to curry favor in a relationship. I've never been able to figure that out. It seems to me that if I'm dating (or have just broken up with) someone who takes a bunch of pills in an effort to make me feel bad, the long-term prospects of that relationship are pretty poor. Whenever I think about this, I'm always reminded of the college student I saw while working in Daytona Beach. He was down there for Spring Break, and found his girlfriend walking the beach with another guy. By the time I saw him, he had already taken a few swings at a paramedic, which meant now he was spread eagled on a cot in four-point restraints, and not in a fun, Stevie Nicks, leather-and-lace filled way.

As I recall, our conversation went something like this:

Me: "Hey, I'm Dr. Rodenberg. What's going on?"

Him: "Fuck you, man."

That's as far as I got in Round 1. The paramedics filled me in on the rest. His girl had gone off with another guy, and he decided to get back at her by taking four...count 'em, four...Tylenol. For the record, I take four Tylenol for a headache. (Yes, I know that's technically an overdose, but I can calculate my weight-based toxic dose so I'm good. The lethal amount can be found online by anyone who's serious about suicide. See above.). He took the Tylenol, then called the girl, who called the police but, in what I can only assume is a flash of insight and maturity, did not return to their hotel room to offer comfort or solace.

There are other educational interventions besides tubes and purgatives. Reality testing, for one.

Me: "So I hear you took some pills to piss off your girlfriend. Where is she? is she here now?"

Him: "She's fucking Bobby."

Me: "So how's that working out for you?"

Him: "Fuck you."

The truth is a harsh mistress. Maybe even worse than an Ewald tube.

(While this particular entry into the blogosphere addresses those who say they want to die but really don't, let's not forget that there are two related groups in this discussion as well. The first are those people who don't want to die but have done everything in their power to do so. These are the morbidly obese, the ones who can't be bothered taking their medications or seeing the doctor. It's those whose eating habits and lack of exercise are practically invitations to death. It's the smokers, the alcoholics, the drug abusers. You can make a case...weakly, in my opinion, but at least more than for fibromyalgia...that these people have different physiology, that they react differently to stressors and stimuli, and that they are subject to unique and oppressive psychosocial and economic factors resulting in health issues that are not really their "fault." There may perhaps be some truth to that, but there's also truth to the fact that we can choose a healthy lifestyle and that we can take advantage of community resources to help us with our issues. Because we're no longer willing to build personal responsibility into our health care policies, we keep wasting time and effort giving first class medical care to those who don't care enough to do their part. I have no problem caring for someone who's done damage to themselves but is now doing their part...quit smoking or drinking, losing weight, following-up with their own physician. For those who accept no responsibility for their own well-being, at some point our expenditures have to stop. The devil, or course, is in the details. The solution lacks the clarity of what we might call the Jean-Luc Picard Limit. (The line must be drawn here! This far, no further! And I will make them PAY for what they have done!)

Sadly, there's also the other category of people with terrible illness who want to die and you absolutely understand why. There are people with terminal cancer in perpetual pain, those in end-stage heart failure or emphysema where every breath is agony, and patients with degenerative neurologic disease who can't move, eat, or speak. If they say they want to die, it's because it's the last moment of control they have over their own lives when disease has stripped them of everything else. We don't do physician-assisted suicide in the ER. But I will ask these patients and their families if they really want to be fully evaluated and admitted, or can we just do something kinder and gentler, like give you some pain medicine for home and perhaps a bit of steroids to improve your appetite? You'll be surprised how many of these kinds of patients just want to go home and be in peace, and they seem grateful that someone's willing to join them on the plank. And I'll confess that, when I sense that's what going on in a patient who can't speak for themselves, when I see that look of resignation in their eyes, I'll choose a tone of voice for the family that suggests the right answer. Sometimes you need to go gently into that good night.)